Lakeside-Milam Recovery Centers Alumni Group
Come join us in the fellowship of the spirit!!
Membership Application Form
(Only requirement for membership is 1) to have been a patient at any Lakeside-Milam
Treatment Center and completed either inpatient, or phase I of IOP, or 2) a family member, or 3)
be a friend of a patient who completed either inpatient, or phase I of IOP.)
Please Print !!
First Name:
Last Name:
Street Address:
City:
State:
Zip:
Day time phone:
Cell phone:
Email Address:
Date of birth:
Gender: Female
Male
Willing to be a phone contact: Yes
No
Willing to be a meeting contact: Yes
No
I also agree to be contacted by written mail, email, or phone by Lakeside-Milam staff, or fellow
Alumni member
Signature
Date
Please return to mailing address below (cut here)
Alumni Group Contact Information
Alumni Coordinator Phone
425-823-3116
Mailing Address:
Alumni Coordinator
c/o Lakeside-Milam Recovery Centers
10322 NE 132nd St
Kirkland, WA 98034
Web Site/Email:
www.lakesidemilam.com/recoverycommunity.htm
mailto: alumni@lakesidemilam.com